A very bad report: gamma minus for the vice-chancellor

A report has appeared on Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine. The report is written by people all of whom have vested interests in spreading quackery. It shows an execrable ability to assess evidence, and it advocates degrees in antiscience It would fail any examination. Sorry, Prof Pittilo, but it’s gamma minus.[Download the report]

“This week came the publication of the “Report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK”. Otherwise known as twaddle.” . . .

“Regulate the practitioners – for safety, note, not for efficacy, as that is impossible to prove – and you give them official recognition. From recognition it is but a short hop to demand and then prescription: packet of Prozac, bit of yoga and a bag of dodgy herbs for you, sir.” . . .

“The Government responded on Monday – with a three-month consultation. So join in. Write to the Health Minister Ben Bradshaw at Richmond House, 79 Whitehall, SW1A 2NS. Write, on behalf of the NHS: “What I want for my 60th birthday is… the chance to provide medical, dental, and nursing care to all. And absolutely nothing else.”

Why is it that a health joutnalist can do so much better than a university head? Yes, the chair of the steering group is Professor R. Michael Pittilo BSc PhD CBiol FIBiol FIBMS FRSH FLS FRSA, Principal and Vice-Chancellor of The Robert Gordon University, Aberdeen. Despite all those impressive-lookin initials after his name, I believe that this is a very bad report.

Professor Michael Pittilo joined The Robert Gordon University, Aberdeen, as Principal and Vice-Chancellor on 5th September, 2005.

After postdoctoral research on arterial disease at the University of London, he was appointed to Kingston University where he became Head of Life Sciences. In 1995 he became Foundation Dean of the Faculty of Health and Social Care Sciences at Kingston University and St George’s Medical School (University of London). He was appointed Pro Vice Chancellor at the University of Hertfordshire in 2001.

Professor Pittilo has held a number of additional roles, including chairing Department of Health working groups, and as a trustee for the Prince of Wales’s Foundation for Integrated Health. “

Notice that Prof Pittilo is a Trustee of the Prince’s Foundation for Integrated Health, source of some of the least reliable information about alternative medicine to be found anywhere.

This steering group is, as so often, a nest of vested interests. It does not seem to have on it any regular medical or clinical scientist whatsoever. Why not? They just might produce some embarrassing facts perhaps? Like most government committees its members seem to have been chosen to produce the desired outcome.

For a start, the university run by Prof Pittilo, Robert Gordon’s University, is itself involved in a few antiscientific courses. Since his report recommends that degrees in quackery should become mandatory, I expect he’d welcome the chance to run more. Amazingly, Robert Gordon’s University runs an Introduction to Homeopathy, just about the daftest of all the common sorts of magic medicine.

Most of the the members of the steering group represent vested interests, though strangely this is not made clear in the list of members. An earlier report, in 2006, from the steering group was more open about this. Twelve of the members of the group represent Herbal Medicine, Chinese Medicine and Acupuncture (four from each). Most of the rest are lay members or bureaucrats. With membership like that it is, I suppose, not surprising that the assessment of evidence is, to put it kindly, grossly distorted and woefully inadequate.

The report starts badly by failing to mention that the House of Lords report (2000), and the government’s response to it, set the following priorities. Both state clearly

“… we recommend that three important questions should be addressed in the following order . .

(1) does the treatment offer therapeutic benefits greater than placebo?

(2) is the treatment safe?

(3) how does it compare, in medical outcome and cost-effectiveness, with other forms of treatment?

The word ‘placebo’ does not occur a single time in the main report (and only twice in the text of the seven appendices). But they do say (page 11):

“We recommend that public funding from the NHS should be used to fund CAM therapies where there is evidence of efficacy, safety and quality assurance.”

The evidence

The problem is that the assessment of the evidence for efficacy in the report is pathetically poor. The report, sad to say, consists essentially of 161 pages of special pleading by the alternative medicine industry, served up with the usual large dose of HR gobbledygook.

There is really no excuse for this utterly incompetent assessment. There have been plenty of books this year alone that make excellent summaries of the evidence, mostly written for the lay public. They should, therefore, be understandable by any university vice-chancellor (president). The one benefit of the upsurge in public interest in magic medicine is that there are now quite a lot of good clinical trials, and when the trials are done properly, they mostly confirm what we thought before: in most cases the effects are no more than placebo.

Here is one example. Annexe1 concerns “Developing Research and Providing an Evidence Base for Acupuncture and Herbal/Traditional Medicine Treatment”. The wording of the title itself suggests, rightly, that this evidence base does not exist, in which case why on earth are we talking about them as “professions”? The discussion of the evidence in Annexe 1 is nothing if not partial. But what do you expect if you ask herbalists to assess herbal medicine? An honest assessment would put them out of business. The eternal mantra of the alternative industry appears as usual, “Absence of evidence is, of course, not evidence of absence”. True of course, but utterly irrelevant. Annexe 1 says

“Acupuncture is a complex intervention and lack of a suitable placebo control has hindered efforts to evaluate efficacy”

This is simply untrue, In recent years enormous efforts have been put into devising controls for assessment of acupuncture, but they are entirely ignored here. One thing that has been established quite clearly is that it makes no difference where you put the needles, so all the talk of Qi and meridians is obvious mumbo-jumbo.

Have the authors of Annexe 1, and Professor Pittilo, not read the relevant studies? Two books this year have dealt with the question of evidence with great care. They are both by people who have been involved personally with acupuncture research, Prof Edzard Ernst and Dr Barker Bausell. Edzard Ernst is the UK’s first Professor of Complementary Medicine. Barker Bausell was research director of an NIH-funded Complementary and Alternative Medicine Specialized Research Center at the University of Maryland.

Singh and Ernst discuss thoroughly the question of controls and assess all the evidence carefully. Their conclusions include the following.

The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch’i [Qi] or meridians.

By focussing on the increasing number of high-quality research papers, reliable conclusions from systematic reviews make it clear that acupuncture does not work for a whole range of conditions, except as a placebo.

In short, the evidence is neither consistent nor convincing. It is borderline.

Barker Bausell was himself involved in designing and analysing trialsof acupuncture. His conclusions are even less positive.

“There is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo”.

These are serious authors with direct experience in CAM research, which is more than can be said of anyone on the steering group. Why are their conclusions ignored entirely? That is sheer incompetence.

Degrees in anti-science

One conclusion of the report is that

“The threshold entry route to the register will normally be through a Bachelor degree with Honours”

This is utter nonsense. It is quite obvious surely that you can’t award honours degrees until after you have the evidence. You can read on page 55 of the report

“3a: Registrant acupuncturists must:

understand the following aspects and concepts for traditional East-Asian acupuncture:

This is utter baloney. Anyone who advocates giving honours degrees in such nonsense deserves to be fired for bringing his university into disrepute (and, in the process, bringing all universities and science itself into disrepute).

If making peole do degrees in mumbo-jumbo is not the answer, what is? Clearly it would be far too draconian to try to ban quackery (and it would only increase its popularity anyway).

The answer seems to me to be quite simple. All that needs to done is to enforce existing laws. It is already illegal to sell contaminated and poisonous goods to the public. It is already illegal to make fraudulent advertisemants and to sell goods that are not as described on the label.

The only problem is that the agencies that enforce these rules are toothless and that there are a lot of loopholes and exceptions that work in favour of quackery. I have tried myself to complain about mislabelling of homeopathic pills to the Office of Fair Trading on the grounds that are labelled Arnica 30C but contain no Arnica. They solemnly bought a bottle and sent it to an analyst and of course they found no arnica, But nothing happened, because an exception to the usual law applies to homeopathic pills.

“Consumers in the United Kingdom are to receive stronger legal safeguards against products that claim, without any identifiable scientific evidence, to provide physical and mental health benefits such as tackling obesity or depression.”

“The scope of the legislation is deliberately wide and is the biggest shake up in consumer law for decades. It targets any unfair selling to consumers by any business.”

Politicians seem to be immune to rational argument when it comes to quackery. But a few legal actions under these laws could bring the house of cards tumbling so fast that this gamma-minus report would become rapidly irrelevant. There will be no shortage of people to bring the actions. I can’t wait.

“It makes it clear that the lunatics have taken over the asylum. For a start, how could Philip Hunt, previously director of the National Association of Health Authorities and Trusts, possibly have thought that “psychic healing” constituted a “profession” – let alone one which would “develop its own system of voluntary self-regulation?”

“One can see how this might fit in with the Government’s “never mind the quality, feel the width” approach to university education. One can also see how established practitioners of such therapies might see this as a future source of income – how pleasant it might be to become Visiting Professor of Vibrational Medicine at the University of Westminster.

Thus garlanded with the laurels of academic pseudo-science, the newly professionalised practitioners of “alternative medicine” can look down on such riff-raff as the “psychic surgeons”

Once again I have to ask, how is it that we have to rely on journalists to prevent vice-chancellors eroding academic standards; indeed eroding simple common sense? I guess it is just another sign of the delusional thinking engendered by the culture of managerialism that grips universities.

40 Responses to A very bad report: gamma minus for the vice-chancellor

It is very depressing when a government department sinks to this level of rigour – or lack of it. In the report two of the ‘criteria for recommending voluntary registers for direct transfer
to the Health Professions Council’ are 1) that an organisation must be in existence for five years and 2) that the ‘minimum size of a viable register will normally be 300 individuals, except where the traditions are extremely small’. How can a tradition be small? This seems to imply that anyone can set up a register of a few people and claim that their ‘therapists’ should be part of the Health Professions Council. Furthermore with private companies increasingly becoming involved in the NHS, there is huge scope for all this quackery to muscle in.

If the public constulation ever appears on the DoH site (why is it not there today?) it is important to encourage plenty of input of common sense and science – I say this even though I am extremely skeptical of farcical public consultations.

What would be the point of a register anyway , when on the Foundation for Integrated Health (where Michael Pittilo is a trustee) website ‘therapists’ are advised, in the section on self-regulation, that

‘Anyone can set themselves up in business as a complementary therapist. While people are not allowed to claim to cure disease, there are plenty of ways to imply it without breaking the law’.

No need to comment except to ask whether this could constitute some sort of incitement to law-breaking.

The problem with expecting CAM to provide evidence of efficacy is that the quotation above from Bausell, “there is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo”, is pretty much a definition of CAM. If there’s good evidence of efficacy it is no longer “complementary” or “alternative”.

Good work, sir. I’ve argued for a while that “our” best bet is through trades descriptions type legislation, and I’m encouraged by the potential of the EU. Presumably such legislation would cover both homeopathic pills and CAM degrees (which, I imagine, cost a lot of money).

I went through the new EU legislation which has two possibly related sections:

“Falsely claiming that a product is able to cure illnesses, dysfunction
or malformations.” This is a direct prohibition regardless of the context or result of the transaction.

There is also:

“misleading information generally” where it may lead to a different consumer decision (hello, homeopathic claims!) and where the information is related to one of many factors including “(a) the existence or nature of the product, (b) the main characteristics of the product” among many others.

I am personally aware of a couple of stores that seem to break these regulations by claiming efficiency of homeopathic products not in the product labels (because this is prohibited!) but in small leaflets or brochures that accompany the products!

I intent to take action when I verify everything. Any other advice would be very welcomed!

Any ideas if/how this could be applied to the CAM Degrees? There is got to be something we can do for these degrees!

Well I think you should try a Flying Spaghetti Monster type approach, and along with a few like-minded individuals, set up a voluntary register of traditional european medicine practitioners, stressing the understanding of disease through the four humours, the dangers of black bile, the benefits of cupping, and the inutility of anaesthetics or sterile procedures before surgery. Then all you would need to do is get Robert Gordon University to set up a BSc in the “subject”.

“You won’t have seen the consultation documents yet on the Department’s website, for the simple reason that they have not yet been written. The intention is to issue them later this summer and to invite comments for a 3-month period ”

Although they wish to keep regulation separate from efficacy, that does not seem to me to be possible: it leads to absurdities.

The official also said that BMJ article about EU rules on fraudulent claims was “very interesting and relevant”. I pointed out that the government would look pretty silly if dozens of their newly-created professionals immediately ended up in court for making unjustified claims. That looks to me like a good line to take when the ‘consultation’ starts.

The ASA, OFT and the courts are going to be very busy. Do you remember Allen Roses (worldwide vice-president of genetics at GlaxoSmithKline)? He said, “The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people.”

Of course the legislation should be used for any unfair practice, whether it comes from the pharmaceutical industry, herbalists or acupuncturists.

I don’t know where those numbers came from, but it wouldn’t surprise me if they are more or less right. Eventually, no doubt, it will be possible to find the reasons for variablity in reponses, and to tailor treatments more precisely to individuals.

That will take a lot of research effort and that effort most certainly won’t be made by herbalists and scupuncturists. In any case, 30 -50% is a lot better than the near-zero response to the sorts of treatments advocated by Anti-D.

A news article in the BMJ today quotes Prof Pittilo stating that “traditional health therapists [presumably the long tradition of quackery and snake oil sales is the tradition referred to here] were in huge demand, with 40% of the general public accessing one at some point”. He also considered that “…the fact that manipulation therapists currently had three regulators—one for osteopaths, one for chiropractors, and one for physiotherapists—was ‘nonsense.’” (BMJ 2008;336:1395 (21 June), doi:10.1136/bmj.a401 (published 18 June 2008). This is a bit rich. Three regulators is not the nonsense. It is the fact that two of these areas of quackery are “professionally regulated” at all that is the nonsense. Surely those legitimate areas coming under the remit of the Health Professionals Council (including physiotherapists, occupational therapists, radiographers, and speech therapists apparently) should be up in arms about being bracketed with practitioners of acupuncture, traditional Chinese medicine, and other alternative therapies.

In the same short article one Michael McIntyre, chairman of the European Herbal and Traditional Medicine Practitioners Association, states that “although regulation was not concerned with proving the effectiveness of alternative or complementary therapies, it would lead to better standards, as greater consistency among practitioners would make it easier for research to be conducted. Once evidence begins to emerge, all practitioners would be expected to follow the best practice…”

So – nothing about efficacy but an expectation of following best practice when it emerges. Surely if this proposal goes ahead the first principle for many of these newly regulated “healthcare professionals” should be to avail themselves of the currently available best evidence and cease practicing and get themselves a real job not reliant on the fears, superstitions, delusions and gullibility of others.

I have to pay £144 every 2 years to the HPC or I can’t practice as a dietitian. Many of my standards of proficiency require evidence of efficacy and the use of up-to-date, good quality research in my practice.

I have e-mailed the HPC asking if the same standards for efficacy will apply to the proposed new ‘health professions’ as to my profession. I will keep you informed.

Interestingly I am required to “recognise the role of other professions in health and social care”, which presumably could mean I can’t tell patient that his/her registered Ayurvedic practitioner was talking rubbish when they said that “Ayurvedic treatment….can increase the digestive process and the elimination of waste & toxins from the body” (The Ayurvedic Clinic, Croydon) thereby promoting weight loss.

There are plenty of examples of animals including primates, rats and birds using herbs for medicinal purposes (mostly preventative rather than therapeutic), as well as to control parasites in their fur or nests. The point is not that the plants evolved to help humans, it’s that animals (including humans) evolved in a world of plants, so a tendency to self-medicate could confer a selective advantage…

‘…so a tendency to self-medicate could confer a selective advantage…’ until the appearance of pharmacologists, who fret over issues like standardisation in plants used for medicine, but not in plants used for food! I haven’t noticed any RCTs or meta-analyses into the benefits of bananas as a foodstuff. Surely these are essential – we can’t rely on traditional knowledge in this area of nutrition…

Anyhow, this thread is about regulation. I think you’ll find that a majority of herbalists will be more than happy if you & the rest of your quackbusting cronies kick up a big stink about SR via the HPC (though they won’t agree with your reasoning). On this particular issue we’re right behind you – keep up the good work!

On page 46 of Pitillo, in Annex 2 presented by the Acupuncture Stakeholders Group, it says:

“Please note all but one of the organisations representing acupuncture
endorsed this paper. There was one organisation that does not wish to be
named, that had a contrary view about some of the aspects of the Annex.”

My guess is that the dissenting organisation is the British Medical Acupuncture Society. Their Medical Director, Mike Cummings, one of the four acupuncture representatives of the steering group, slated the report by Dr Xiaorui Zhang of the WHO, mentioned in the Annex. He says:

“The one obvious and major limitation to this report is the way in which clinical trials evidence is cited and interpreted. While a considerable volume of research is cited, the methods used for the search and data analysis are not systematic. Indeed, the report indicates that negative or neutral sham-controlled studies were not generally included.”

“It is clear that this report is highly biased in favour of acupuncture; indeed, this commentator had the opportunity to hear a presentation from the author in April 2003. At that presentation, Dr Zhang said that the paper was written: ‘… to show acupuncture works.’ As such, this unsystematic review cannot be used to support the contention that acupuncture is efficacious.”